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nvaaoD  oi  I  Repeated  pregnancy  i 

RECAP 


FrarG.^  A,    Stahl 


Repeated  pregnancy  ii  the  sair.e  tube;  a  case 
of  homotopio  and  homositic  repeated  tubal  pregnancy* 


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Repeated  Pregnancy  in  the  Same 

Tube :  A  Case  of  Homotopic 

and  Homositic  Repeated 

Tubal  Pregnancy 


FRANK  A.  STAHL,  M.D. 
Chicago 


The  American  Journal   of   Obstbtbics 

Vol.  XLIV.,No.  4,  Wn 


NEW   YORK 

WILLIAM   WOOD    &  COMPANY,    PUBLISHERS 

1901 


REPEATED  PREGNANCY  IN  THE  SAME  TUBE:  A  CASE  OF 

HOMOTOPIC  AND  HOMOSITIC  REPEATED 

TUBAL  PREGNANCY. 


Repoets  of  CiiSes  of  repeated  pregnancy  in  the  same  tube  are 
still  so  few  in  number  that  up  to  the  present  writing  but  three 
undoubted  cases  Jaave  been  recorded— Haydon's,  1863;  Coe's, 
1893;  Heinricius',  1899.  This  evening  I  will  report  the  fourth. 
Though  these  three  were  same-sided  in  repetition,  they  were 
not  same-sited.  The  present  report  will  place  on  record  a  case  of 
repeated  same-sided  and  same-sited  tubal  pregnancy— to  coin  a 
word,  a  case  of  homotopic  and  homositic  repeated  tubal  preg- 
nancy. It  is  unique  in  character.  Both  pregnancies  were  recog- 
nized before  the  patient  entered  the  hospital.  Her  first  case 
holds  the  record  for  deliberate  diagnosis  as  to  early  period  of  ex- 
trauterine gestation ;  three  celiotomies^  were  performed  within 
twenty-one  months  upon  the  same  patient;  following  the  two 
celiotomies  for  the  right-sided  repeated  pregnancies,  a  third 
celiotomy  was  performed  for  the  removal  of  the  cystic  degener- 
ated left  ovary ;  the  lady,  roseate  with  color,  is  present  this  even- 
ing, and,  as  you  see,  enjoying  vigorous  health. 

Case  I.— The  first  case  was  reported  by  N.  J.  Haydon^  in 
1863  to  the  London  Obstetrical  Society— "two  fetuses  found  in 
connection  with  the  same  tube."  The  sacs  occupied  different 
sites  in  the  right  tube.     The  condition  was  found  post  mortem. 

Case  II.— The  second  case  was  reported  by  H.  C.  Coe,  of  New 
York,  before  the  American  Gynecological  Society.  Its  extrauter- 
ine nature  was  recognized  at  the  operation.  His  case  was  the 
first  of  its  kind  reported  that  recovered.  (For  further  particu- 
lars of  both  cases  see  Transactions  of  the  American  Gynecologi- 
cal Society,  1893.) 

Case  III. — The  third  case  was  reported  by  Heinricius  and 
Kolster.     Its  nature  was  recognized  post  mortem.^ 

Presented  before  the  Chicago  Gynecological  Society,  May,  1901. 
1  See  Off.  Trans.,  vol.  v.,  1863,  p.  280. 
^Archiv  fiir  Gyn.,  Bd.  Iviii.,  1899,  p.  95. 

Copyright,  nilliam  Wood  &  Company. 


2  STAHL  :    REPEATED    PREGNAXCY    IX    SAME    TUBE. 

History.— Bix  years  ago  Mrs.  K.  S.,  aged  33,  noticed  a  grad- 
ually increasing,  movable,  firm  tumor  in  the  abdomen.  Men- 
struation had  ceased  six  months ;  during  this  time  the  tumor 
increased  in  size;  patient  thought  herself  pregnant.  Since  re- 
turn of  menses  the  tumor  decreased  in  size  until  in  the  autumn 
of  1896,  by  which  time  the  tumor  had  declined  to  the  size  of  a 
fist.  In  the  early  part  of  1897  the  tumor  commenced  to  grow 
again ;  in  April  she  felt  movements  therein,  which  ceased  in  Au- 
gust, since  which  time  she  reports  a  decline  in  the  size  of  the 
abd.omen.  In  ]\Iay,  edema  of  face  and  feet.  Since  June  she  com- 
plains of  a  severe  cough  (tubercular)  and  loss  of  strength. 
When  entering  Helsingfors  Clinic,  September,  1897,  the  diag- 
nosis could  not  be  fixed  with  any  certainty.  The  history  sug- 
gested a  retained  dead  intrauterine  fetus,  though  repeated  exam- 
ination failed  to  find  fetal  parts ;  aside  from  the  history  a  large 
fibroid  was  suggested.  A  smooth,  firm  tumor  could  be  felt  in 
abdomen,  extending  from  symphysis  to  midway  between  umbili- 
cus and  xiphoid  process  and  laterally  to  a  finger's  breadth  of 
the  anterior,  superior  spinous  processes.  During  the  repeated 
examinations  undertaken  no  fetal  parts  were  to  be  felt,  likewise 
no  sounds  audible.  No  light  from  the  use  of  the  Eoentgen  rays. 
Diagnosis  in  suspensio.  October  10,  cer^dx  dilated  mth  lami- 
naria  tent  and  Hegar  's  sounds  to  touch  with  finger ;  could  find  no 
fetal  parts.  October  13,  peritonitis;  October  16,  exitus  lethalis. 
At  the  postmortem,  opening  the  tumor  (from  the  left  tube)  a 
well-developed  fetus  of  51  centimetres  was  found ;  macroscopical- 
ly  no  maceration.  Cutting  into  a  boggy  second  mass  alongside 
the  mature  fetus,  there  were  found  fetal  bones  and  bone  frag- 
ments, considered  remnants  of  a  previous  pregnancy. 

Case  IV.— History  of  my  case.  It  is  fulsome,  yet  interesting. 
Aside  from  the  pregnancies  and  operations,  it  shows  to  what 
traumatic  extremes  a  gjniecean  pelvis  may  be  exposed  and  still 
a-ecover. 

I\Irs.  X.,  5  feet  4  inches  in  height,  weight  125  pounds,  now  28 
years  of  age;  physically  normal.  Childhood  and  family  his- 
tory without  pathological  importance.  First  menstruated  at  14 
years;  three  to  five  days,  always  regular  and  painless.  Course 
of  first  pregnancy  normal ;  normal  in  position ;  normal  delivery 
by  midmfe  of  eight-pound  boy  November  21,  1893 ;  second  stage 
two  hours ;  third  stage  half  an  hour.  Puerperium  such  that  she 
arose  on  the  seventh  day,  but  from  then  on  to  when  I  first  saw  her, 
in  July,  1897,  there  is  a  history  of  a  pelveo-para-perimetritis. 


STAHL  :    EEPEATED   PREGNANCY   IN    SAME    TUBE.  3 

Menstruation  irregular,  so  painful  as  to  be  confined  to  bed ;  con- 
gress painful;  on  the  whole,  a  dragging  existence  so  far  as 
household  duties  and  eomforts  are  concerned.  Not  pregnant 
since  first  labor. 

Fi7^st  Pregnancy  and  Operation. — Right  ampuUary  tubal 
pregnancy.  In  July,  1897,  she  first  came  to  me.  The  findings 
were :  uterus  enlarged,  fixed,  and  painful  when  moved ;  cellu- 
litis less  on  right  side ;  right  ovary  not  tender ;  left  ovary  mark- 
edly painful;  locally  and  systemically,  the  signs  of  a  prolonged 
pelveo-peritonitis.  Locomotion  painful  and  hesitating;  exhaus- 
tion, anxious  pelveo-peritonitic  countenance.  From  July  to 
November  office  treatment  only — as-^patient  lived  some  five  miles 
from  the  office — with  tampon  and  douches  locally,  alteratives 
and  tonics  internally.  By  that  time  her  improvement  was  so 
marked  that  she  could  resume  her  full  household  duties,  locomo- 
tion being  free  and  upright;  pelvic  touch  no  more  painful; 
menstruation  again  regular  and  without  pain;  restoration  of 
cheerful  countenance.  About  November  20,  when  one  week  over 
time,  blood  appeared,  patient  thinking,  though  late,  it  was  a 
regular  menstruation.  Second  day  after  she  noticed  blood  com- 
ing every  half  hour  or  so,  and  then 'clotted,  accompanied  with 
uterine  pains  as  in  labor.  Toward  evening  she  noticed  a  piece 
of  flesh-like-appearing  mass,  probably  the  uterine  decidua;  no 
pains  directly  over  ovaries,  though  sore  all  over  lower  abdomen 
and  pelvis.  Went  to  bed ;  got  up  again  the  next  morning,  when 
she  was  able  to  resume  her  housework.  During  the  week  before 
the  initial  metrorrhagia  she  noticed  morning  sickness ;  disgust  at 
the  smell  of  coffee;  belching  and  heartburn  after  eating  break- 
fast; afternoon  and  evening  could  eat  regularly  without  dis- 
tress ;  tickling  in  the  breasts ;  feeling  of  pelvic  fulness  and  bloat- 
ing ;  clothes  becoming  tight,  etc.  Until  about  the  25th  of  Novem- 
ber she  flowed  as  described,  and  flow  would  cease  for  some  hours, 
conveying  thought  of  cessation  and  being  clean,  when  flow 
would  reappear.  Continued  thus  irregularly  without  large  show- 
ing until  December  4,  when  she  came  to  me  for  advice.  Upon 
examination  without  anesthesia  I  found  the  uterus  soft,  slightly 
enlarged,  fixed  as  before,  mth  signs  of  a  slight  flow;  cervix  not 
open  as  in  an  incomplete  abortion  of  ten  days '  standing ;  on  the 
right  side  of  the  uterus  a  small,  firm  tumefaction,  not  painful 
upon  palpation.  Diagnosis,  extrauterine  pregnancy  of  a  few 
weeks'  standing.  Tamponed,  gave  a  sedative,  and  requested  her 
to  return  in  two  davs,  when  I  found  the  tumor  still  the  same 


4  STAHL  :    REPEATED   PREGNANCY   IN    SAME    TUBE. 

and  decided  on  operation  rather  than  longer'  empiric  treatment. 
I  would  call  attention  here  to  the  marked  assistance  rendered, 
in  the  consideration  of  the  diagnosis,  by  the  patient's  reply  as  to 
morning  sickness,  vomiting,  distaste,  etc.,  her  words  being: 
"Doctor,  I  do  not  know  why  it  is,  but  in  the  morning  I  feel  like 
vomiting,  yet  during  the  day  it  clears  up  and  in  the  evening  I 
can  eat  most  ravenously. ' '  The  statement  recurs  that  not  much 
stress  can  be  laid  upon  the  symptom  of  early  morning  sickness, 
vomiting,  etc. 

Patient  entered  the  Presbyterian  Hospital  December  11,  1897 ; 
Case  No.  19690.  Operated  on  December  15;  ether  narcosis. 
Opening  the  abdomen,  quite  a  typical  picture  of  ruptured  tubal 
pregnancy  presented.  Hemorrhage  was  of  two  kinds :  the  serum 
and  clots  indicated  the  results  of  a  hemorrhage  of  several  days 
before ;  the  bright-red  blood,  the  blood  from  the  existing  hemor- 
rhage. The  active  hemorrhage  fortunately  did  not  come  from  an 
important  artery.  The  ovum  had  attached  itself  to  the  fim- 
briated extremity  of  the  right  tube.  To  use  a  figure,  it  lay  in  the 
fimbrise  like  an  apple  in  the  palm  of  an  outstretched  hand.  In 
growing,  or  through  traumatism,  the  ovum  had  detached  itself 
only  in  a  part  of  its  circumference ;  naturally  here  was  repeated 
a  like  process  to  that  seen  in  a  partial  separation  of  the  mem- 
branes from  the  uterus  in  an  intrauterine  pregnancy.  In  this 
case  hemorrhage  occurred  more  as  an  oozing  than  as  a  flow  from 
the  separated  surfaces.  As  a  consequence  the  ovum,  still  par- 
tially attached,  became  surrounded  by  a  clot;  outside  of  the  clot 
the  oozing  continued— a  process  the  counterpart  of  the  fleshy 
mole  in  intrauterine  pregnancy.  In  reaching  down  for  investi- 
gation, the  sensation  conveyed  to  the  fingers  in  touching  the  clot- 
ovum  was  just  like  that  received  in  encountering  a  piece  of  ad- 
herent placenta  in  a  curage  for  retention.  The  sensation  was 
so  true  that  the  internes  were  invited  to  touch  the  adherent  clot- 
ovum.  No  cutting  was  necessary  to  remove  the  clot;  simply 
shelling  it  off,  as  in  a  curage  in  an  incomplete  abortion,  sufficed 
to  release  the  clot-ovum.  There  was  nothing,  else  of  a  patho- 
logical nature  requiring  correction,  the  tube  and  ovary  appear- 
ing not  to  deserve  removal.  Therefore  the  only  indication  was, 
to  control  the  oozing  from  the  raw  surfaces  of  the  fimbrige.  To 
accomplish  this  the  fimbrise  were  simply  folded  over  and  their 
borders  stitched  together  by  means  of  a  continued  catgut  suture. 
It  will  be  well  to  bear  this  in  mind,  for  where  union  with  oc- 
clusion of  the  fimbriae  was  looked  for  patency  persisted,  this 


STAHL:    REPEATED   PREGNANCY   IN    SAME    TUBE.  O 

suture  notwithstanding,  as  will  be  seen  in  the  account  of  the 
subsequent  pregnancy.  The  peritoneum,  especially  that  of  the 
contiguous  bowels,  was  actively  hyperemic,  suggestive  of  a 
threatening  peritonitis.  The  uterus  was  found  firmly  bound 
to  the  rectum  by  a  thick  band  of  adhesion,  this  causing  the  fix- 
ation of  the  uterus  mentioned  above  and  its  retroflexion.  This 
band  was  dissected,  releasing  the  retroflexed  uterus.  In  closing, 
an  abdominal  hysteropexy  was  made  and  abdomen  closed  as 
usual.  Her  condition  coming  from  the  operation  was  bad, 
respirations  shallow,  skin  cold.  For  the  following  seventy-two 
hours  her  condition  continued  critical,  demanding  repeated  salt, 
whiskey,  and  strychnia  hypodermatics.  In  truth,  were  it  not 
for  the  unusual  skill  and  untiring  vigilance  shown  by  my  house 
interne.  Dr.  J.  D.  Freeman,  and  his  assistants,  I  doubt  very 


Fig.  1  —Illustration  of  gestation  clot  removed  at  the  first  operation.  AmpuUary  form  of 
right  tubal  pregnancy.  Clot  broken  open,  showing  the  gestation  sac  of  about  the  second 
or  third  week.     Diameter  of  ovule  in  siiecimen,  seven  millimetres.    Original  size. 

much  that  I  should  have  been  able  to  record  this  case  in  so 
happy  a  frame.  After  these  three  days  recovery  was  slow,  yet 
constant.  She  was  discharged  January  22,  1898.  Her  stay  in 
the  hospital  was  prolonged  by  slight  transitory  pleuritis  mani- 
festing itself  during  the  third  week.  At  home  again,  it  was 
only  after  the  third  month  that  she  could  resume  her  full  house- 
hold duties ;  no  pelvic  discomfort ;  no  scalding  urine,  so  distress- 
ful before ;  menstruation,  formerly  at  times  so  painful  that  she 
was  compelled  to  take  to  bed  and  use  sedatives,  now  when 
menstruation  recurred  it  did  so  without  disagreeable  prodromata 
and  without  pain,  first  knowledge  being  due  to  signs  of  blood. 

Another  interesting  feature  in  this  case  is  that,  about  four 
months  after  she  left  the  hospital,  wishing  to  attend  church 
services,  she  walked  some  distance.  For  some  reason  the  uterus 
became  liberated  from  its  attachment  to  the  abdominal  wall. 


b  STAHL  :    REPEATED   PREGNANCY   IN    SAME    TUBE. 

as  a  consequence  of  which  a  series  of  symptoms  developed,  such 
as  vomiting,  increased  temperature,  a  one-day's  flow  from  the 
uterus,  bright  red  in  color,  not  pale  as  is  characteristic  of  the 
pseudo-menstruation  in  extrauterine  pregnancy.  At  a  certain 
point  to  the  left  of  the  uterus  I  found  a^  tumefaction  which  sug- 
gested the  possibility  of  another  extrauterine  pregnancy.  I 
mention  this  feature  to  show  how  easy  it  is  at  times  to  think  of 
the  presence  of  another  such  pregnancy  where  one  has  previous- 


FiG.  2.— A,  mass  made  up  of  right  tube  and  ovary,  removed  at  second  operation.  Origi- 
nally a  repeated  ampullary  form  of  right  tubal  pregnancy:  now  tubo-ovarian.  B.  the 
thinned  wall  of  the  fimbriated  portion  only,  separating  the  placenta  from  contact  with  the 
ovary.  There  is  no  direct  connection  between  the  blood  supply  of  th^  two  ovaro-tubo- 
placental  circulations.  C,  ge.s'tation  sac  showing  placenta,  fetus,  and  cord  of  about  the 
sixth  to  eighth  week.  D,  site  of  rupture  of  the  fimbria?,  show. ng  clot  (E)  plugging  opening, 
thus  checking  free,  active  hemorrhage.  Fetus  and  cord  macerated,  undergoing  absorp- 
tion. F,  ovary  shows  a  still  fresh  corpus  luteum,  which  furnished  the  ovule  for  the  second 
pregnancy.    G,  i-esected  tube.    Original  size. 


ly  occurred.  This  swelling  must  have  been  due  to  the  slight 
hemorrhage  and  to  the  exudate  from  the  irritation  incidental 
to  the  separation  of  the  uterus  from  its  abdominal  attachment. 
This  all  cleared  up  with  douches,  tampons,  and  rest. 

Second  Pregnancy  and  Operation. — Repeated  right  ampullary 
tubal  pregnancy.  Patient  continued  well  until  last  regular 
menstruation  in  January,  1899.  Toward  the  end  of  February 
she  noticed  morning  sickness,  morning  loss  of  appetite,  fulness 


STAHL  :    REPEATED   PREGNANCY   IN    SAME   TUBE.  7 

of  breasts.  A  slight  flow  had  shown  itself  for  two  days. 
Though  alarmed,  since  she  continued  to  feel  well  she  grew  easier. 
Continued  her  household  duties  as  usual.  March  25  she  went 
down  one  flight  of  steps  to  carry  up  coal.  She  is  of  quite 
strong  muscles.  Shovelling  two  cgal  buckets  full,  no  discom- 
fort followed.  But  in  lifting  the  two  buckets  at  once,  intend- 
ing to  carry  them  up  at  the  same  time,  she  was  suddenly  seized 
mth  a  sharp,  lancinating  pain  in  the  right  side,  dizziness  and 
vertigo,  but  did  not  fall.  She  waited  a  moment  to  recover,  sup- 
porting her  sides  with  her  hands  as  though  to  prevent  some- 
thing from  falling  through  the  pelvic  floor.  After  a  few 
moments  she  had  recovered  to  such  an  extent  that  she  carried 
up  one  pail,  then  came  down  and  carried  up  the  second  pail. 
By  this  time  the  abdominal  pains  had  become  so  severe  that  she 
was  compelled  to  go  to  bed,  where  she  applied  a"  liniment  to  the 
abdomen.  About  one  hour  after  she  arose,  though  without 
acute  pain,  yet  with  a  sense  of  pelvic  soreness.  The  next  Sun- 
day she  walked  a  distance  of  one  mile.  This  coal-household 
traumatism  had  occurred  twelve  days  before  she  called  me. 
During  this  time  she  had  done  her  own  housework,  heavy  wash- 
ing, etc.,  without  pain,  only  a  feeling  of  soreness  in  the  lower 
abdomen  and  discomfort.  The  following  Wednesday  morning 
she  had  taken  some  Hunyadi  water;  in  the  bathroom,  while 
movement  occurred,  she  grew  faint,  and  when  movement  finished 
she  fainted.  Intense  pain  followed,  recovering  so  she  could 
hobble  to  bed ;  no  uterine  hemorrhage  whatever.  When  I  called, 
the  patient  presented  a  picture  of  severe  peritoneal  irritation. 
Examination  found  a  firm,  rounded,  oblong  tumor  at  same  site 
of  previous  operation.  In  reply  to  the  suggestion  that  she  was 
pregnant,  she  answered  that  she  had  been  happy  in  the  thought 
that  she  was,  and  that  since  the  attack  of  twelve  days  before 
she  feared  some  serious  disaster  similar  to  the  first.  Diagnosis, 
without  anesthesia,  repeated  right  ampuUary  pregnancy.  She 
entered  the  Presbyterian  Hospital,  the  second  time,  April  9, 
1899:  Case  No.  22627.  Operation  April  12;  chloroform 
narcosis.  Abdomen  clear  of  hemorrhage ;  no  adhesions ;  mass 
of  right  tube  and  ovary,  containing  pregnancy  of  about  six 
weeks,  removed  close  up  to  the  uterus  without  difficulty.  The 
reason  that  there  was  no  free  hemorrhage  into  abdominal  cavity 
will  be  seen  by  referring  to  the  accompanying  illustration  (Fig. 
2).  The  interval  marking  where  rupture  of  fimbrise  of  tube 
had  taken  place  was  plugged  up  by  a  firm  clot,  fortunately 


S  STAHL:    REPEATED   PREGNANCY   IN    SAME   TUBE. 

checking  both  hemorrhage  and  opening.  The  left  ovary  seemed 
smaller  than  usual,  but  was  without  cysts.  Uterus  well  in  its 
perpendicular,  no  traces  of  former  bands  of  adhesion  either  to 
rectum  or  abdominal  wall.  Patient  returned  from  operation, 
in  fairly  good  condition.  Her  recovery  was  prompt,  patient 
going  home  after  the  fifth  week.  Household  duties  resumed 
"without  discomfort. 

Third  Operation. — For  cystic  degeneration  of  left  ovary. 
Patient  again  presented  herself  at  office  for  diagnosis  because- 
of  a  slight  bright-red  hemorrhage  from  the  uterus.  In  the  in- 
terval since  the  last  operation  she  had  enjoyed  good  health. 
Menstruation  regular  and  "without  pain.  Examination  yielded 
a  fluctuating,  rounded  tumor  to  the  left  of  the  uterus— a  cystic 
ovary.  Entered  hospital  for  the  third  time  September  20.  1899 ; 
Case  No.  23764.  September  21,  operation ;  chloroform  narcosis. 
No  adhesions.  Easily  removed  the  mass,  made  up  of  the  cystic- 
degenerated  left  ovary  and  part  of  that  tube.  The  patient  re- 
turned from  the  operation  in  good  condition.  Discharged 
October  11. 

Subsequent  History. — For  some  seven  months  after  third  op-^ 
eration  patient  speaks  of  a  monthly  complex  of  symptoms,  such 
as  flushes  of  heat,  nervousness,  irritability,  and  a  feeling  of 
general  malaise — as  she  expresses  it,  "as  though  she  wanted 
to  be  sick  (menstruation)  and  could  not" — corresponding  in  time 
to  that  of  her  previous  periods.  She  never  has  had  even  a  sign 
of  blood  since  the  last  operation.  This  monthly  complex  I  at- 
tributed to  the  continued  but  declining  irritability  of  that  part 
of  the  menstrual  cycle  still  remaining.  This  has  gradually 
passed  away.  As  to  her  present  physical  condition,  as  you  see 
to-night,  May  29,  1901,  she  is  weU  and  in  splendid  health. 

Other  Cases. — Other  cases  presumed  to  have  been  repeated 
same-sided  tubal  pregnancy  have  been  recorded,  viz.,  by  Alban 
Doran,  J.  W.  Taylor,  T.  F.  Pre\^att,  Gottschalk,  Bennington, 
and  the  latest  by  P.  A.  Harris,  of  Paterson,  N.  J.^  These  can- 
not be  included  among  the  undoubted  because  of  insufficiency^ 
of  laudable  evidence. 

The  Impossible  in  Tubal  Pregnancy. — Included  in  the  account 
of  Haydon's  case  is  a  "Report  on  Specimen,  by  Dr.  Tyler 
Smith  and  J.  Braxton  Hicks.  From  hence  we  infer  the  fol- 
lowing: 1.  That  some  time  since  (five  years  before)  the  patient 
had  conceived  extrauterine :  that  the  fetus  was  attached  to  the 
'  Medical  News,  vol.  Ixxvi.,  1900,  p.  561. 


STAHL:    REPEATED   PREGNANCY   IN    SAME   TUBE.  9 

^mbriated  extremity  of  the  Fallopian  tube  (left)  in  such  man- 
ner as  not  to  form  impediment  to  subsequent  conception;  that 
this  fetus  died  at  about  the  second  month  of  pregnancy,  enclosed 
still  in  its  o\T^ilar  structure ;  that  it  then  dwindled  gradually  away 
to  its  present  state,  the  chorion  villi  being  absorbed,  2.  That 
at  a  later  period,  probably  some  months  before  death,  she  again 
conceived,  also  extrauterine,  but  the  ovum  had  this  time  de- 
scended to  the  middle  of  the  tube;  that  it  was  there  arrested, 


Fig.  3. — From  a  section  of  the  right  tube  close  to  the  gestation  sac.  The  specinien  from 
which  this  section  is  taken  shows  a  U-twist  in  the  tube:  undoubtedly  the  salpinyitis- with 
this  twist  caused  such  a  stenosis  of  the  lumen  at  this  point  as  to  permit  of  sufficient  space 
for  the  passage  of  the  spermatozoa  to  the  waiting  ovule,  but  was  so  nar/  ow  that  it  checked 
at  this  point  the  passage  of  the  larger  ovum  in  its  course  toward  the  uterus.  Congestion 
with  hypertrophy. 

lived  about  three  months,  and  then  died,  three  months  after 
which  the  sac  bursted  ensued." 

It  seems  rather  strange  that  this  report  by  so  well-known 
writers  as  Drs.  Smith  and  Hicks  should  meet  with  such  em- 
phatic doubt  as  that  expressed  by  a  subsequent  writer  and  one 
also  well  known  for  his  work  on  the  tubes  and  ovaries.  Speak- 
ing of  repeated  tubal  gestation,  J.  Bland  Sutton^  writes:  ''Parry 
has  grouped  under  this  heading  several  cases  of  women  who 
"have  been  known  to  bear  more  than  one  extrauterine  child;  but 
.   ^  Diseases  of  Tubes  and  Ovaries. 


10  STAHL  :    REPEATED   PREGNANCY   IN    SAME   TUBE. 

it  may  be  at  once  stated  that  of  the  nine  cases  adduced  by 
Parry,  not  one  can  be  regarded  as  of  the  least  value  in  establish- 
ing such  an  occurrence.  Indeed,  in  one  instance  he  is  so 
credulous  as  to  believe  that  tubal  pregnancy  may  happen  twice 
in  the  same  tube.  The  case  in  question  is  reported  in  great 
detail  by  Dr.  Haydon,  whose  account  is  supplemented  by  a  re- 
port on  the  specimen,  signed  by  Drs.  Tyler  Smith  and  Braxton 
Hicks.  This  paper  is  illustrated  by  a  plate,  from  which  it 
seems  exceedingly  probable  that  the  patient  had  a  bicornate 
uterus.-  Repeated  gestation  in  the  same  tube  is  an  impossibility, 
for  the  pregnancy  produces  such  gross  changes  as  to  render  it 
f  unctionless. ' ' 

So  writes  Sutton  in  1891.  Whatever  doubt  may  have  seemed 
justified  then,  to-day,  in  view  of  the  incontrovertible  evidence 
.as  furnished  by  these  later  cases  (2  and  3),  there  can  be  no 
more  room  for  doubt,  not  even  for  a  purely  technical  one,  such 
as  possible  other-sided  migration  of  the  ovum  with  subsequent 
implantation.  For,  aside  from  Coe's  and  Heinricius'  cases,  my 
case,    as   shown   by   its   history   and   by   illustrations   of   both 

=  Not  only  Sutton  (1891)  regards  this  case  as  doubtful.  Likewise 
Varnier  and  Sens  (Annales  de  Gynecologie  d'Obstetrique,  Mars,  1901, 
pp.  170-171),  in  referring  to  this  case,  include  it  among  the  "elles 
manquent  de  la  precision  anatomique  et  clinique  qu'on  est  en  droit 
d'exiger  pour  des  faits  aussi  extraordinaires,  viz.,  N.  P.  Haydon,  W. 
Taylor,  T.  Prewitt,  Gottschalk,  et  Alban  Doran." 

The  writer  prefers  to  include  Haydon's  case  among  the  undoubted. 
For  if  the  doubt  be  based  only,  as  it  seems,  upon  the  presumption 
that  there  was  a  bicornate  uterus  present,  over  against  that  view  lies 
the  fact  that  Drs.  Smith  and  Hicks  spoke  of  that  uterus  in  a  way 
implying  a  normal  development,  so  far  as  the  uterus  itself  is  con- 
cerned, as  may  be  seen  in  the  following:  "Uterus  nearly  four  inches 
long,  two  inches  wide.  The  walls  proportionately  thick.  Interior  of 
uterus  lined  with  a  very  thick  decidual  membrane,  now  easily  separ- 
able. This  layer  is  quite  as  thick  as  is  found  in  normal  gestation 
at  its  fullest  development,  and  under  the  microscope  is  found  to  pos- 
sess the  elements  of  the  decidua  of  pregnancy"  (from  their  report). 

A  bicornate  uterus  under  those  circumstances  would  be  so  pregnant 
a  uterine  developmental  anomaly  that  the  gentlemen  could  not  avoid 
its  recognition,  and,  I  dare  say,  would  not  avoid  its  annotation.  Nor 
does  it  follow  as  a  consequence  that,  given  a  bicornate  uterus,  a  uni- 
lateral or  a  repeated  homotopic  extrauterine  pregnancy  is  impossible. 
The  slightest  dipping  down  of  the  fundus  of  the  uterus  of  my  case 
would  have  brought  it  within  the  range  of  the  bicornate  uteri. 
Though  it  must  be  admitted  a  septum,  complete  or  partial,  might  in- 
fluence such  occurrence,  yet  the  etiological  factors  lie  essentially 
extrauterine,  beyond  the  cornua. — S. 


STAHL:    REPEATED    PREGNANCY    IN    SAME    TUBE. 


11 


-pregnancies,  with  the  still  fresh  corpus  luteum  of  the  right 
ovary,  removing  all  doubt  as  to  the  origin  of  the  second  ovum, 
meets  all  his  objections.  Therefore  I  would  offer  these  con- 
clusions : 

1.  Repeated  gestation  in  the  same  tube  does  occur.  In  fact, 
the  ease  Avith  which  such  a  primary  tubal  pregnancy  may  pass 
unrecognized  and  have  comparative  health  follow  would  strongly 
suggest  that  a  more  frequent  occurrence  of  repetition  takes  place 
than  is  reported. 


Fig.  4.— From  a  section  of  the  left  tube  close  to  the  cyst.    Tube  markedly  twisted. 
Fibrosis  with  atrophy. 

2.  Repeated  gestation  in  the  same  tube  (or  other  part,  as 
abdomen)  is  not  an  impossibility;  it  occurs. 

3.  It  does  not  follow  that  a  former  pregnancy  produces  such 
gross  changes  as  to  render  it  (the  part)  functionless. 

Etiology.— The  right  tube  and  ovary.  Ovary,  some  inflam- 
matory round-cell  infiltration,  slight  in  character.  The  fresh 
corpus  luteum  shows  ovary  possessed  of  good  physiological  func- 
tion. Tube,  slight  torsion  near  fimbrise ;  epithelia  of  tube  uterine- 
ward  from  sac,  microscope  shows  them  to  be  swollen  and  over- 
ripe, but  nowhere  is  there  loss  of  epithelial  cells  or  exposure  of 
the  basement  membrane.  Slight  round-cell  infiltration  into  other 
coats — a  picture  of  a  mild  salpingitis. 

The  left  tube  and  ovary  show  microscopically:   Ovary,  cystic, 


12  STAHL:    REPEATED   PREGNANCY   IN    SAME   TUBE, 

monolocular,  seven  by  four  and  a  half  centimetres;  marked 
fibrosis  and  pressure  atrophy  with  disappearance  of  paren- 
chyma. Tube,  a  similar  condition  of  fibrosis,  complete  loss  of 
epithelium,  so  picture  looks  like  branches  without  leaves.  Both 
functionless.  Firm  occlusion  of  fimbriae.  Marked  torsion  of 
the  tube.  The  etiological  factor  of  left-side  sterility  is  plain, 
chronic  salpingitis  and  ovaritis,  due,  as  also  the  slight  inflam- 
matory changes  of  the  right  side,  to  the  septic  pelvic  trouble 
following  the  first  labor. 

In  the  early  fifties  Virchow  ascribed  salpingitis  with  its 
changes  as  the  important  etiological  factor  in  extrauterine  preg- 
nancy, its  inflammatory  exudation  stiffening  the  tubal  coats, 
Clausing  impairment  to  its  ovum-carrying  functions.  Since  then 
much  has  been  recorded  pro  and  con,  especially  within  the  last 
fifteen  years.  It  would  be  impractical  to  mention  even  a  few 
of  these  many  writers  or  their  opinions  in  detail.  It  will  suffice 
to  mention  several  to  show  the  trend  that  obstetrical  thought 
is  assuming  to-day.  Contrary  to  this  opinion,  Edgar  writes^ 
in  his  report  of  a  case  of  repeated  extrauterine  pregnancy  "that 
he  found  no  pathological  changes  and  is  of  the  opinion,  like 
other  authorities,  that  salpingitis  plays  no  important  role." 

On  the  other  hand,  Moscowicz-  presents  two  cases  in  which 
he  associates  tubal  pregnancy  with  tubal  infection. 

Franz^  also  favors  salpingitis  as  etiological  factor.  He  ad- 
vances the  theory— and  I  venture  to  say  that  this  is  the  popular 
opinion  accepted  to-day  (aside  from  those  cases  due  to  anomalies 
of  development,  as  accessory  tubes,  etc.) — that  extrauterine 
pregnancy  occurs  in  convalescent  tubes,  in  which  the  ovum-car- 
rying function  of  the  tube  is  disturbed  for  a  time  and  eventually 
has  been  gradually  but  imperfectly  re-established.  So  far  as 
my  case  is  concerned,  its  history,  clinical,  macroscopical,  and 
microscopical,  shows  salpingitis  (following  the  pelvic  sepsis 
after  the  first  labor)  as  the  important  factor  in  its  etiology, 
confirmatory  of  Virchow 's  early  and  Franz's  to-day  opinion. 

Query :  Why  was  not  the  right  tube  and  ovary  removed  at  the 
primary  operation?  Conservatism:  In  conversation  with  the 
patient,  and  which  in  spirit  was  repeated  each  time,  she  begged : 
"Doctor,  don't,  don't— oh,  you  know,  please  don't.  I  love  my 
husband  and  we  both  love  children,  so  please  spare  them  if  you 
possibly  can."     I  offer  no  other  argument. 

^  Edinburgh  Medical  Journal,  July,  1899,  p.  35. 

=  Centralblatt  fiir  Gynakologie,  Bd.  xlii.,  1899,  p.  1290. 

'Centralblatt  fur  Gynakologie,  Bd.  xlii.,  1899,  p.  1290. 


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